Presentation and management of diabetic ketoacidosis in ...€¦ · Presentation and management of diabetic ketoacidosis in adults in Malta Miriam Giordano Imbroll, Alison Psaila,

Editorial OrgOdRe

Original Article

Malta Medical School Gazette Volume 03 Issue 03 2019

Abstract

Aim: The aim of this audit was to assess

adherence to local guideline in the management of

Diabetic Ketoacidosis (DKA).

Method: Patients admitted with DKA between

April 2013 and March 2015 were identified and

data was retrospectively collected from patients’

confidential files and Isoft®. Data collected

included initial parameters recorded and

biochemical investigations taken (initial and

subsequent assessment of pH, HCO3-, blood glucose,

potassium levels and urinary ketones), insulin

regime started and intravenous fluid administered.

Results: During the established time period 40

cases of DKA were identified in 18 patients.

Median age was 33 years with a female

preponderance of 60%. Six patients had newly

diagnosed diabetes mellitus while 8 patients had

more than one admission of DKA. All cases had

capillary blood glucose monitoring (BGM) and/or

venous random blood (plasma) glucose (RBG)

checked and pH and HCO3- recorded on admission.

0.9% sodium chloride was the intravenous fluid

started in all cases (as recommended by the

guideline) and a median of 6.75L was prescribed

during the first 24 hours. The median time spent on

intravenous insulin infusion was 42.7 hours while

the median time to pH >7.30, HCO3- >15mmol/L

and negligible urinary ketones were 6.88, 12.83 and

34.5 hours respectively. Subcutaneous insulin was

started at a median time of 48.21 hours from

initiation of DKA protocol.

Conclusion: This audit showed good adherence

to local guideline. The great discrepancy between

the time to pH >7.3 and the time to negligible

urinary ketones highlights the need to introduce

tools to measure systemic ketone production in the

management of DKA with an update in the current

local clinical practice guideline.

Presentation and management of diabetic

ketoacidosis in adults in Malta

Miriam Giordano Imbroll, Alison Psaila, Alexia-Giovanna Abela,

Mark Gruppetta, Sandro Vella, Josanne Vassallo, Mario J. Cachia,

Stephen Fava Miriam Giordano Imbroll MD MRCP *

Department of Medicine,

Faculty of Medicine and Surgery, University of Malta,


Mater Dei Hospital, Msida, Malta.

[email protected]

Alison Psaila MD MRCP



Department of Medicine, Mater Dei Hospital, Msida, Malta.

Alexia-Giovanna Abela MD MRCP





Mark Gruppetta MD PhD



Department of Medicine, Mater Dei Hospital, Msida, Malta.

Sandro Vella MD (Melit) MD (Dund)





Josanne Vassallo MD PhD


Faculty of Medicine and Surgery, University of Malta, Department of Medicine,


Mario J. Cachia MD FRCP





Stephen Fava MD PhD


Faculty of Medicine and Surgery, University of Malta, Department of Medicine,


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Original Article


Keywords

Diabetes type 1, Diabetic Ketoacidosis,

Complications, Mater Dei Hospital

Introduction

Diabetic ketoacidosis (DKA) is defined by the

biochemical triad of ketone production,

hyperglycaemia and acidaemia. Although not

common, mortality from DKA is approximately

2%,1 however, each death is potentially avoidable.

Increasing patient and healthcare professional

education and awareness of DKA and its

management, has led to a decline in mortality over

recent years.

The current audit aimed to assess the

management of patients with DKA and compare

these practices with the local DKA guideline issued

in 2007.3 Changes in current practice that could

improve patient care and shorten hospital stay will

be identified and instituted.

Methods

All adult patients (>16years of age) admitted

with DKA to Mater Dei Hospital (MDH) over a two

year period, between April 2013 and March 2015

were identified. These were identified from the

Accident and Emergency (A&E) admission book

and the Electronic Case Summary system. Patients’

confidential files and Isoft® investigations were

analysed in detail and predefined data sets obtained,

in line with Data Protection Act. Only patients with

parameters fulfilling the biochemical triad of DKA:

1) blood glucose > 11.0mmol/L or known to have

diabetes mellitus, 2) metabolic acidosis with HCO3-

<15.0mmol/L and/or venous pH < 7.3 and 3)

significant ketonuria > 2+ on standard urine sticks,

were included in the study.4 The identified patients

had their DKA management analysed in detail and

compared to the current DKA guideline3 available

at MDH. All data was recorded on Microsoft Excel

spreadsheet and analysis of data was then

performed using IBM SPSS® version 22.

Kolmogorov–Smirnov test was carried out to

determine the normal distribution of the data and

then either T-Test / ANOVA (for parametric data)

or Mann-Whitney U / Kruskal–Wallis or χ2 (for

non-parametric data) tests were used as appropriate.

Correlation analyses were carried out using

Spearman correlation.

Results

1. Demographics

Using the criteria above to define DKA, 40

cases (n = 40) were identified in a total of 18

different patients, during the study period. In the

cases studied the median age was 33 years (IQR 24

– 52.25) with a female predominance of 60%. Six

patients (33.3%) had newly diagnosed diabetes. 8

patients (44.4%) had more than one admission with

DKA during the studied period.

2. Initial Assessment and investigations

Vital parameters (temperature (T), systolic

blood pressure (SBP), Glasgow coma scale (GCS),

oxygen saturation (SO2%) and pulse (P)) at

presentation, as documented in casualty were

analysed (Table 1).

On admission all patients had recorded bedside

capillary blood glucose monitoring (BGM). BGM

was recorded as ‘HI’ in 7 cases, while the median

reading in 32 cases was 25.7mmol/L (IQR 23.48 –

30). Venous random blood (plasma) glucose (RBG)

was documented in 29 cases and the median was

33.6mmol/L (IQR 25.2 – 37.4). All 40 cases had pH

and HCO3- levels checked, in 33 cases by an arterial

blood gas (ABG) and 7 cases by a venous blood gas

(VBG) analysis. The median pH of the study

population at presentation was 7.18 (IQR 7.11 –

7.24) while the median value for HCO3- was 7.4

(IQR 5.4 – 11.45). A urine sample confirming

ketonuria was obtained in 22 cases in the A&E

Department.

Additional investigations recommended by the

current DKA guideline3 include a complete blood

count (CBC), renal profile (U&E, Cr), arterial blood

gases (ABG), urinalysis, pregnancy test in female

patients, ECG and chest x-ray (CXR). An amylase

level is recommended in patients with abdominal

pain. The frequency and results of these tests in

concordance to the local guideline is illustrated in

Table 1.

All cases were admitted to Mater Dei Hospital,

with 4 cases requiring admission to intensive

therapy unit (ITU).

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Table 1: Parameters and investigations with respective median results measured at admission

Table 2: Frequency of ABG/VBG testing with median results for pH and HCO3-

Time of

ABG/VBG (hrs from start

of protocol)

Frequency

(n)

Percentage

(%) Median pH

(mmHg) (IQR) Median HCO3- (mmol/L) (IQR)

0 40 100 7.19 (7.11 - 7.25) 7.4 (5.4 - 11.45)

2 33 82.5 7.22 (7.18 - 7.27) 8.7 (5.4 - 13.2)

4 29 72.5 7.27 (7.22 - 7.31) 8.6 (7.2 - 13.7)

8 35 87.5 7.33 (7.28 - 7.37) 14 (12.2 - 16.6)

12 33 82.5 7.36 (7.34 - 7.40) 16.6 (15.4 - 19.0)

24 14 35 7.42 (7.36 - 7.43) 18 (16.6 - 20.5)

Parameters and

investigations on

admission

Frequency (n) Median (Interquartile Range)

Temperature (℃) 38 36.4 (36 - 36.8)

GCS 40 15

Oxygen saturation (%) 37 99 (98 - 99)

SBP (mmHg) 39 121 (107 - 134.5)

Pulse rate (/min) 39 103 (93 - 120)

White cell count (x109/L) 40 13.55 (8.78 - 19.98)

Creatinine (μmol/L) 40 104 ( 94.75 - 120.5)

eGFR (mls/min/1.73m2) 40 60.5 (48.25 - 71.25)

Amylase (U/l) 24 39 (35 - 76.75)

ECG 39 n/a

CXR 33 n/a

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Table 3: Frequency of K level checked and median level at time interval 0, 2, 4, 8, 12 and 24 hours from start

of DKA protocol

3. ABGs/VBGs

According to current local DKA guideline, pH

and HCO3- should be measured at 2, 4, 8, 12 hours

after starting the protocol or until normalisation of

metabolic acidosis. All patients had ABGs/VBGs

repeated until pH and HCO3- levels had normalised

but not necessarily within the stipulated time

intervals (see table 2).

4. Ketones

The current DKA guideline recommends

measuring urinary ketones every 4 hours until

clearance is achieved. Ketones were checked

regularly in 38 cases (95%) during the first 24

hours, while 29 patients still required urinary ketone

testing for more than 24 hours after starting DKA

treatment protocol. In the initial 24 hours after

starting treatment the median number of times

urinalysis was performed was 4 times (IQR 3 –

5.75) with a median of 2 times (IQR 1 – 3) at 24 –

48 hours.

5. BGM

Hourly BGM checks are recommended in the

current local DKA guideline, for patients on

intravenous insulin infusion. The median number of

BGM checked was 17.5 times (IQR 9.75 – 22.25)

during the first 24 hours and 4 times (IQR 3 – 5.75)

at 24 – 48 hours from admission.

6. Insulin administration

All cases studied were treated with a variable-

rate insulin infusion (VRIII) of short-acting insulin

(Actrapid®). Long-acting basal insulin together with

intravenous Actrapid® was co-administered in 4

cases (10%). The median time spent on Actrapid®

infusion was 42.7 hours (IQR 27.9 – 65.75). During

this period of time the median number of units of

insulin required was 89Units (IQR 65 – 114) in the

first 24 hours of protocol and 66Units (IQR 54.5 –

83) at 24 – 48 hours. Total insulin dose in the first

24 hours was positively correlated with initial RBG

(ρ=0.381, P= 0.024). In 7 cases (18%), a further

increase in insulin was required to reach target

BGM.

7. Intravenous fluids

All patients were started on 0.9% of sodium

chloride in concordance with the local guideline.

The patients received a median of 6.75L (IQR 6.11

– 7.45L) during the first 24 hours. 10 cases (25%)

did not require intravenous fluid for more than 24

hours, while 30 cases (75%) received a median of

2L (IQR 0.5 – 2.72L) at 24 – 48 hours from starting

DKA protocol.

Intravenous fluids are to be changed to 5%

dextrose in normal saline if BGM is less than

11mmol/L and to 10% dextrose if BGM is less than

5mmol/L in the current local DKA guideline.

Intravenous fluids were correctly changed in 36

cases when BGM fell below 11mmol/L. In 10 cases

BGM fell less than 5mmol/L during the initial 24

hours and 9 of these cases had the intravenous fluid

correctly changed to 10% dextrose.

Time of K (hrs from start of protocol)

Frequency of K level checked n

(%) Median K level (mmol/L)

(IQR)

0 40 (100) 4.7 (4.2 – 5.1)

2 31 (78) 4 (3.4 - 4.4)

4 29 (73) 4.3 (3.9 - 4.5)

8 35 (88) 3.8 (3.5 - 4.4)

12 32 (80) 3.9 (3.5 - 4.1)

24 22 (55) 3.7 (3.2 - 4.1)

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Table 4: Correlation between different parameters in DKA management

Results in bold are statically significant (P<0.05) p: Spearman rank-order correlation coefficient; P: Significance (two-tailed)

Initial pH Initial RBG

Age Systolic BP on

admission

Initial Potassium

WCC on admission

eGFR on admission

Total

Insulin given in

1st 24 hrs

Time Period till pH.>7.3

Time

Period till HCO3-

>15

Time Period till

urine Ketones -

ve

Hours on Actrapid

pump

HCO3- ρ 0.560 -0.323 -0.500 -0.386 0.070 -0.630 0.487 -0.296 -0.396 -0.0630 -0.444 -0.497

P <0.001 0.058 0.764 0.017 0.672 <0.001 0.002 0.071 0.014 <0.001 0.023 0.001

Initial pH ρ -0.041 0.304 -0.231 0.002 -0.253 0.200 0.072 -0.579 -0.520 -0.141 0.026

P 0.814 .056 0.158 0.991 0.115 0.216 0.662 <0.001 0.001 0.483 0.872

Initial RBG ρ 0.475 -0.309 0.406 0.419 -0.747 0.381 0.108 0.140 0.409 0.544

P 0.003 0.066 0.014 0.009 <0.001 0.024 0.530 0.429 0.038 0.001

Age ρ 0.074 0.314 0.194 -0.325 0.244 -0.046 -0.150 -0.090 0.333

P 0.655 0.049 0.231 0.041 0.134 0.781 0.370 0.654 0.036

Systolic BP on admission

ρ -0.236 0.028 0.181 -0.080 0.237 0.200 -0.302 0.020

P 0.148 0.865 0.271 0.633 0.152 0.235 0.125 0.905

Initial Potassium ρ 0.288 -0.191 -0.036 -0.127 0.017 -0.039 0.104

P 0.072 0.238 0.825 0.441 0.919 0.849 0.523

WCC on admission

ρ -0.406 0.349 0.224 0.500 0.545 0.566

P 0.009 0.029 0.170 0.001 0.003 <0.001

eGFR on

admission

ρ -0.328 -0.264 -0.309 -0.325 -0.589

P 0.041 0.105 0.059 0.098 <0.001

Total Insulin given in 1st 24 hrs

ρ -0.050 0.182 0.091 0.403

P 0.767 0.281 0.658 0.011

Time Period till pH.>7.3

ρ 0.544 0.015 0.165

P 0.001 0.941 0.315

Time Period till HCO3- >15

ρ 0.544 0.494 0.390

P 0.001 0.010 0.015

Time Period till urine Ketones -ve

ρ 0.015 0.494 0.436

P 0.941 0.010 0.023

Hours on Actrapid pump

ρ 0.165 0.390 0.436

P 0.315 0.015 0.023

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8. Potassium supplementation

The current guideline suggests checking

potassium (K) levels at 2, 4, 8, and 12 hours and to

add supplemental potassium chloride into the

intravenous fluid solution according to results.

Table 3 shows frequency and results of K level at

the time intervals recommended. Correlation

analysis showed K levels at presentation to be

positively correlated with increasing age and RBG

(ρ=0.314, P=0.049 and ρ=0.406, P=0.014

respectively). (Table 4)

9. Additional management

In 7 cases insulin was infused via pump at a

higher rate than recommended by protocol while in

2 cases the intravenous fluids prescribed after

admission differed by both rate (infused at a

standard rate of 128mL/min) and type (Hartmann’s

solution) respectively from what is recommended in

the guideline. Furthermore, 2 patients were

prescribed sodium bicarbonate.

Antibiotics were prescribed in 23 patients. 10

patients had no documented source of infection, 5

patients had documented respiratory tract infection,

4 patients had a urinary tract infection, 2 patients

had gastroenteritis while one patient had antibiotics

started for pelvic inflammatory disease. White cell

count on admission was found to be negatively

correlated with initial HCO3- and eGFR (ρ=-0.630,

P=<0.01 and ρ=-0.406, P=0.009 respectively), but

positively correlated with initial RBG levels

(ρ=0.419, P=0.009) and time to resolution of DKA

(ρ=0.545, P=<0.01) (Table 4).

Urinary catheterisation was performed in 11

cases during admission. Reason for catheterisation

was documented as haemodynamic instability in 5

cases, acute kidney injury in 4 cases and in 2 cases

this was undocumented.

10. Time to resolution of DKA

According to our local guidelines, DKA is

considered resolved and fixed doses of

subcutaneous insulin are recommended to be

restarted once pH and bicarbonate are normal,

normoglycaemia is achieved, urine is free of

ketones and patient is eating normally. Using these

criteria time to resolution of DKA and time spent

on DKA protocol (taken as the time to

subcutaneous insulin) were determined. These

results are shown in Figure 1. Most of the 4

variables which were taken as indicative of

resolution of DKA correlated positively with each

other as shown in Table 4.

Discussion The main aim of this audit was to assess

adherence of current practices to the local

guidelines and identify areas for improvement in the

management of DKA.

From the whole cohort, 8 patients had more

than one admission. Seven patients had 2

admissions and one patient had 11 admissions.

Recurrent admissions with DKA is associated with

multiple factors including poor control,

noncompliance and nonattendance to outpatient

clinic, female gender, presence of co-morbidity and

psychological problems.2 From the cohort of

patients with readmissions, 6 patients were females,

4 patients were non-compliant to treatment, 1

patient had underlying pancreatic tumour and 1

patient had steroid-induced DKA. The patient with

11 admissions with DKA had an underlying

psychological disorder.

All patients had BGM checked on admission.

Median RBG was noted to be significantly higher

than median BGM (33.6mmol/L and 25.7mmol/L

respectively). In 7 cases (17.5%) the BGM value

was unrecordable as point of care machines are not

able to give a numerical reading at very high levels.

The median BGM was therefore underestimated as

these 7 cases were excluded from the calculated

BGM median.

Deviation from protocol was noted in some

cases. All 40 cases had pH and bicarbonate levels

measured. 33 cases (82.5%) had an ABG

measurement, whilst 7 cases (17.5%) had a VBG

measurement on admission. Current local guideline

recommends taking ABGs until normalisation of

pH and taking VBGs in difficult cases if general

condition is improving.3 Guidelines issued by the

Joint British Diabetes Societies (JBDS) Inpatient

Care Group4 suggest measuring venous rather than

arterial bicarbonate and pH as the difference

between venous and arterial pH is 0.02 – 0.15 pH

units and the difference between arterial and venous

bicarbonate is 1.88mmol/L. This negligible

difference will neither impact diagnosis nor

management of DKA.5

In 18 cases (45%) a urine sample was not

available for measuring urinary ketones at the A&E

department for various reasons including inability

of patients to pass urine, dehydration and low GCS.

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According to the JBDS guidelines one of the

criteria defining DKA is a serum ketonaemia of ≥

3.0mmol/L or significant ketonuria of ≥ 2+ on

standard urine sticks.4 Locally ketone meters are not

available yet and this may delay the detection of

ketones in patients who are unable to provide a

urine sample at A&E. Ketone meters detect β-

hydroxybutyrate which is the main type of ketone

produced in DKA as opposed to acetoacetate

detected by the standard urine dipsticks. The latter

also sometimes gives false positive results and the

presence of acetoacetate in urine lags behind the

actual systemic ketone production, therefore

delaying both diagnosis and resolution of DKA.6

Local guideline recommends use of a VRII and

in 7 cases (18%), a further increase in insulin

treatment recommended. Updates in JBDS

guideline suggest using a fixed-rate insulin infusion

(FRII) rather than VRII. FRII consists of

prescribing a fixed insulin regime according to

weight, thus partially accommodating for the very

obese patients4 and enabling rapid ketone clearance.

In 4 cases (10%) long-acting insulin (glargine) was

continued together with intravenous short-acting

insulin infusion. Continued use of background

insulin avoids rebound hyperglycaemia when

intravenous insulin is stopped and should also

shorten duration of inpatient stay.7

Initial intravenous fluid recommended in

current guideline is 0.9% NaCl, which is to be

changed to 5% dextrose in 0.9% NaCl if BGM <

11mmol/L and to 10% dextrose if BGM

<5mmol/L3. This recommendation was adhered to

in 36 cases (90%). This represents a significant

improvement from observations in a previous audit,

in which correct change in intravenous fluids was

observed in 71.4% of cases.8 Patients in DKA often

have mild to moderate hyperkalaemia at diagnosis,

despite a total body deficit of potassium. The

initiation of insulin further lowers circulating

potassium as it shifts potassium intracellularly,

potentially resulting in severe hypokalaemia.9

Hence close attention needs to be given to

potassium levels, in order to avoid complications

associated with hypokalaemia, including cardiac

arrhythmias, arrest and respiratory muscle

weakness.4 Data on potassium supplementation

differs. The American Diabetes association

guidelines suggest the addition of 20-30mmol of

potassium in each litre of infusion fluid to maintain

a potassium level between 4 and 5mmol/l,10

whereas the JBDS guidelines4 recommend replacing

with a dose of 40mmol/L of potassium if serum

level is less than 5.5mmol/l.

An elevated WCC was negatively correlated

with HCO3- and pH levels, although the latter did

not reach statistical significance (p = <0.001 and p

= 0.115 respectively). DKA is associated with an

elevated level of proinflammatory cytokines,

reactive oxygen species, and adhesion molecules

which all contribute to the increased WCC.11

Assessment of resolution of DKA was based on

normalisation of pH, HCO3- and urinary ketones

level. From our results, pH levels returned to

normal at the shortest time interval, followed by

HCO3- and urinary ketones respectively (Fig. 1).

From our data HCO3- correlated well with the 2

other variables measured for the resolution of DKA.

However JBDS guidelines recommend not using

HCO3- as the only variable due to possible

hyperchloraemia secondary to large volumes of

0.9% sodium chloride solution used as fluid

replacement. Consequent hyperchloraemic acidosis

may lower HCO3- levels and lead to difficulty in

assessing for resolution of ketosis.4

The limitations of this audit include missing

data from files and observation charts. Unclear and

incomplete documentation also limited extraction of

relevant data for this audit. Nonetheless, the audit

performed showed numerous strengths including

correct diagnosis of patients on presentation to

A&E, accurate assessment of fluid balance and

BGM management, accurate documentation of time

at which subcutaneous insulin was restarted and of

resolution of DKA.

Conclusion

In the current local guideline the diagnosis and

resolution of DKA is based on pH, bicarbonate and

detection /lack of ketones in the urine. Results from

our audit for resolution of DKA have highlighted

the great discrepancy between the time taken to

achieve a pH >7.3mmHg (7.38hrs) and the time

taken to achieve negative ketones in the urine

(26.25hrs). The difficulty in obtaining a urine

sample to test for ketones early on presentation and

the persistent detection of ketones in the urine after

suppression of ketonaemia contribute to the delay in

diagnosing DKA and in identifying resolution of

DKA respectively. This might result in potentially

harmful delays in initiating treatment of DKA and

subsequent unnecessary prolonged treatment with

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insulin infusion. The introduction of ketone meters

to measure ketones in the blood would expedite

DKA diagnosis, facilitate monitoring of the patient

admitted with DKA and accurately identify

resolution of DKA early while the administration of

insulin infusion at a fixed rate, tailored to the

individual patient according to the patient’s weight,

would contribute to rapid ketone clearance thus

improving the overall management of the patient

admitted with DKA.

References 1. Johnson DD, Palumbo PJ, Chu C-P. Diabetic

ketoacidosis in a community-based population. Mayo

Clin Proc 1980;55:83–88.

2. Wright J, Ruck K, Rabbitts R, Charlton M, De P, Barrett

T, Baskar V, Kotonya C, Saraf S, Narendran P. Diabetic

ketoacidosis (DKA) in Birmingham, UK, 2000—2009: an evaluation of risk factors for recurrence and mortality.

Br J Diabetes Vasc Dis 2009 Nov;9(6):278-82.

3. CPG: Mater Dei Hospital. Diabetic Ketoacidosis in

Adults Management Guideline, 2007.

4. Joint British Diabetes Societies Inpatient Care Group.

The Management of Diabetic Ketoacidosis in Adults.

Revised September 2013. http://www.diabetologists-abcd.org.uk/subsite/JBDS.

5. Ma OJ, Rush MD, Godfrey MM, Gaddis G. Arterial

blood gas results rarely influence emergency physician

management of patients with suspected diabetic

ketoacidosis. Acad Emerg Med 2003; 10(8):836-841.

6. Laffel L. Ketone bodies: a review of physiology, pathophysiology and application of monitoring to

diabetes. Diabetes Metab Res Rev 1999 Nov

1;15(6):412-26.

7. Hsia E, Seggelke S, Gibbs J, Hawkins RM, Cohlmia E,

Rasouli N et al. Subcutaneous administration of glargine

to diabetic patients receiving insulin infusion prevents

rebound hyperglycemia. J Clin Endocrinol Metab 2012;

97(9):3132-3137

8. Abela AG, Magri CJ, Debono M, Calleja N, Vassallo J, Azzopardi J. An audit of the management of diabetic

ketoacidosis at St Luke’s Hospital. Malta Med J.

2008;20(2):16-21.

9. Tran TT, Pease A, Wood AJ, Zajac J, Martensson J,

Bellomo R and Ekinci EI. Review of Evidence for Adult

Diabetic Ketoacidosis Management Protocols. Front Endocrinol 2017;8:106

10. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN.

Hyperglycemic crises in adult patients with diabetes.

Diabetes Care. 2009;32(7):1335-43

11. Xu W, Wu HF, Ma SG, Bai F, Hu W, Jin Y, Liu H.

Correlation between peripheral white blood cell counts

and hyperglycemic emergencies. International journal of medical sciences. 2013;10(6):7

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Presentation and management of diabetic ketoacidosis in ...€¦ · Presentation and management of diabetic ketoacidosis in adults in Malta Miriam Giordano Imbroll, Alison Psaila,